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Fill Out the Orofacial Myofunctional Questionnaire

Myofunctional Questionnaire

Please complete this form to the best of your abilities.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Medical History

  • Including: loss of oxygen, fetal distress, NICU stay, and any other complications during pregnancy, delivery, or the newborn phase.
  • Feeding History

    Please do not skip this section, even if you do not have feeding concerns.
  • Select all that apply. My child:
  • Please list any and all bottles and/or feeding systems attempted to date:
  • Social History

  • Nighttime/Sleep Breathing